Apical periodontal disease
The apical periodontitis ( lat. Apical at the top ', ancient Greek παρά para , German , in addition' , ὀδούς , tooth ' and -ίτις -itis for inflammatory disease'; also: apical periodontitis , apical osteitis or root tip inflammation ) is an inflammation at the tip of the root of a tooth and is one of the odontogenic infections . For marginal periodontitis (starting from the gum line) see Periodontitis .
root cause
Apical periodontal disease is a bacterial inflammation. The bacteria get from pulpitis (inflammation of the tooth pulp) through the root canal or through deep gum pockets to the tip of the root. The cause is a carious defect that serves as an entry point for pathogens and does not necessarily cause pain in the beginning. In addition, a tooth fracture or a treatment trauma, for example from grinding the tooth for a tooth crown , can lead to pulpitis. Acute pulpitis can be extremely painful. In some cases this inflammation of the pulp is almost painless, the pulp slowly dies and the germs spread in the system of the root canals and ultimately emerge into the surrounding jawbone. As a defense reaction of the immune system, the poorly supplied bone is broken down and replaced by granulation tissue with better blood supply. Apical periodontitis can be acute or chronic. The acute form is often associated with pain; under certain circumstances it can only be verified radiologically with difficulty, while chronic apical periodontitis can be clearly visible in the x-ray image if the bone structure in the area of the root apex is broken down. One then speaks of an apical granuloma . More rarely, apical periodontitis is not caused by bacteria, but by chemical stimuli from a root filling or a medicinal root insert.
Symptoms
There are many signs of apical periodontitis. These include a negative reaction to a sensitivity test , a dull, continuous pain with and without intra- or extraoral swelling. There may also be an active fistula . Radiographically, periapical radiolucency can be detected. With chronic apical periodontitis there are additional episodes of pain. In symptomatic apical periodontitis, acute or subacute clinical symptoms in the form of continuous pain or pain intervals are possible. In addition to the possible strong bite and percussion sensitivity, apical tenderness may be added, with reddening or swelling.
With acute inflammation, the patient feels an apparent elongation of the teeth. The inflammatory secretion at the tip of the root lifts the tooth in the alveolus, as the Sharpey fibers that anchor the tooth in the alveolus give the tooth a certain vertical freedom. This leads to typical bite pain. Often the tooth is already sensitive to the touch of the tongue.
Gradient forms
Apical periodontitis can be acute (primarily acute apical periodontitis) or chronic (primarily chronic apical periodontitis). The chronic form has little or no pain.
When the primarily chronic form turns into acute inflammation, typical knocking pain occurs. Radiographically , apical lightening can usually only be recognized after the disease has progressed for several weeks. The first sign is an enlarged periodontal gap . Changes in bone density can only be seen in the X-ray image when at least 30% of the mineral content of the bone has broken down. In the case of apical ostitis, this can take a few days to weeks. In the case of minor complaints and uncertain informative value of the X-ray image, a repeat exposure is only appropriate after three months.
Indices
In order to facilitate the evaluation of endodontic dental films and to simplify the assessment of the condition of the periapical region and, if possible, to standardize it, various indices have been developed, including the Periapical Probability Index (PRI) by Reit and Grondahl and the Periapical Index (PAI) by Ørstavik.
| PRI 1 | certainly no pathological finding |
| PRI 2 | probably no pathological finding |
| PRI 3 | pathological findings uncertain |
| PRI 4 | probably pathological finding |
| PRI 5 | certain pathological finding |
| 1 | definitely no apical periodontitis |
| 2 | apical periodontitis probably not present |
| 3 | unsure whether apical periodontitis is present |
| 4th | apical periodontitis is likely present |
| 5 | Apical periodontitis is definitely present |
Differential diagnosis
The distinction between apical periodontitis and a dentogenic cyst (radicular cyst) is only possible histologically. The older doctrine that radiographic clearances over 7 mm in diameter rather suggest a cyst has been rejected. Likewise, that a sharply demarcated edge in the X-ray image speaks more for a cyst.
therapy
The therapy consists of a root canal treatment . The localization of the causative tooth can sometimes be difficult because the complaints radiate to the neighboring teeth.
Depending on the value of the abutments , an extraction should be considered as an alternative to root treatment . Especially if there is already severe marginal bone loss, severe tooth loosening or severe carious destruction of the crown.
Apical periodontitis with an existing root filling
Occasionally, apical periodontitis occurs on teeth that have been treated with root canals a long time ago. In these cases a revision (renewal) of the root filling or a root tip resection (ESC) is indicated. Here, the root tip of the tooth is removed, in which secondary canals of the root canal with residual devitalized pulp tissue often run - due to their small size, which cannot be treated.
Apical resection
After about a year, a root canal treatment is subjected to an X-ray control to check whether the apical periodontal has completely healed. If this is not the case, a root tip resection may be necessary even after regular root canal treatment. Only granulomas regress after a successful root canal treatment, while cysts cannot heal completely and can go away.
Another indication for a root tip resection is given if the apically inflamed tooth does not remain symptom-free during the root canal treatment or if symptoms recur. The apicectomy is performed either at the same time as the root filling or later if necessary.
Secondary diseases
If apical periodontitis is not treated, a purulent inflammation can spread in the jawbone, an apical abscess or a radical cyst can develop from it.
See also
Individual evidence
- ↑ a b Michael Hülsmann: Endodontics . Georg Thieme Verlag, 8 October 2008, ISBN 978-3-13-156581-5 , pp. 63–.
- ^ C. Reit, HG Grondahl: Application of statistical decision theory to radiographic diagnosis of endodontically treated teeth. In: Scandinavian journal of dental research. Volume 91, Number 3, June 1983, pp. 213-218, ISSN 0029-845X . PMID 6576461
- ↑ D. Orstavik, K. Kerekes, HM Eriksen: The periapical index: a scoring system for radiographic assessment of apical periodontitis. In: Endodontics & dental traumatology. Volume 2, Number 1, February 1986, pp. 20-34, ISSN 0109-2502 . PMID 3457698 .
